Paper #36: Multi-level Congenital Deformities in Early Onset Scoliosis: Radiographic and Clinical Outcomes in Growth Friendly Graduates

Treatment of complex congenital scoliosis with growth friendly instrumentation led to only modest correction of major curves, residual imbalance, minimal gain in spine and thoracic height and a high incidence of complications. It is unknown whether this treatment improves upon the natural history or early fusion.

Paper #34: Treatment of Severe Early Onset Scoliosis using Distraction Based Spinal Instrumentation : A matched comparative study

Severe EOS can be treated as effectively with distraction instrumentation in comparison to less severe EOS.

Perioperative and Delayed Major Complications Following Surgical Treatment of Adolescent Idiopathic Scoliosis

BACKGROUND

Reporting accurate surgical complication rates to patients and their families is important in the management of adolescent idiopathic scoliosis (AIS). In this study, we report the rate of major complications following the surgical treatment of AIS both in the perioperative period and among patients with a minimum of 2 years of follow-up.

METHODS

We reviewed the prospectively collected data of a multicenter registry of patients who underwent surgical treatment of AIS during the period of 1995 to 2014 in order to identify all complications. A complication was defined as "major" if it resulted in reoperation or in spinal cord or nerve root injury, or was life-threatening. A total of 3,582 patients with preoperative and early postoperative data (4 to 6 weeks of follow-up) were included. A subset of 2,220 patients with a minimum of 2 years of follow-up comprised the cohort for delayed complications. Overall complication rates were calculated, as was the percentage of complications according to the year of the index surgery and type of surgical approach.

RESULTS

The mean age of the 3,582 patients at the time of surgery was 14.8 ± 2.2 years. The average major curve magnitude was 56° ± 13° for thoracic curves and 51° ± 11° for lumbar. In 365 patients, anterior spinal fusion (ASF) with instrumentation was performed, and in 3,217 patients, posterior spinal fusion (PSF) with instrumentation was performed; 142 patients in the PSF group underwent concomitant anterior release. There were 192 major complications, with 93 (2.6%) occurring perioperatively. Perioperative complications included wound-related (1.0% of the patients), neurologic (0.5%), pulmonary (0.4%), instrumentation-related (0.4%), and gastrointestinal (0.2%) complications. One patient died. The mean annual perioperative major complication rate based on the year of surgery ranged from 0% to 10.5%. The complication rate by surgical approach was 3.0% for ASF and 2.6% for PSF (2.4% for PSF only and 5.6% for PSF with anterior release). The major complication rate for the 2,220 patients with at least 2 years of follow-up was 4.1%; all but 1 had a reoperation (4.1%). The majority of these major complications were wound and instrumentation-related (1.9% and 0.8%, respectively).

CONCLUSIONS

After surgery for AIS, a 2.6% rate of perioperative major complications and a 4.1% rate of major complications at 2 or more years after surgery can be anticipated. The complication rate decreased over the period of study.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Resource Utilization in Adolescent Idiopathic Scoliosis Surgery: Is There Opportunity for Standardization?

INTRODUCTION

Recent healthcare reforms have raised the importance of cost and value in the management of disease. Value is a function of benefit and cost. Understanding variability in resources utilized by individual surgeons to achieve similar outcomes may provide an opportunity for cutting costs though greater standardization. The purpose of this study is to evaluate differences in use of implants and hospital resources among surgeons performing adolescent idiopathic scoliosis (AIS) surgery.

METHODS

A multicenter prospective AIS operative database was queried. Patients were matched for Lenke curve type and curve magnitude, resulting in 5 surgeons and 35 matched groups (N = 175). Mean patient age was 14.9 years and curve magnitude 50°. Parameters of interest were compared between surgeons via ANOVA and Bonferroni pairwise comparison.

RESULTS

There was no significant difference in percentage curve correction or levels fused between surgeons. Significant differences between surgeons were found for percentage posterior approach, operative time, length of stay (LOS), estimated blood loss (EBL), cell saver transfused, rod material, screw density, number of screws, use of antifibrinolytics, and cessation of intravenous analgesics. Despite differences in EBL and cell saver transfused, there were no differences in allogenic blood (blood bank) use.

CONCLUSION

Significant variability in resource utilization was noted between surgeons performing AIS operations, although radiographic results were uniform. Standardization of resource utilization and cost containment opportunities include implant usage, rod material, LOS, and transition to oral analgesics, as these factors are the largest contributors to cost in AIS surgery.

Risk Factors of Proximal Junctional Kyphosis in Adolescent Idiopathic Scoliosis-The Pelvis and Other Considerations

STUDY DESIGN

Prospective multicenter database study.

OBJECTIVES

To assess the incidence of proximal junctional kyphosis (PJK) in operative adolescent idiopathic scoliosis (AIS) using contemporary surgical techniques and to identify risk factors for PJK.

SUMMARY OF BACKGROUND DATA

The incidence of PJK has been reported as high as 46% in AIS. Factors associated with PJK have been incompletely explored.

METHODS

Prospectively enrolled 851 AIS patients (2000-2011, 78.5% female, average 14.4 years) were evaluated 2 years postoperatively. Radiographic and sagittal spinopelvic parameters and rod contour angle (RCA), a new measure that reflects the proximal contouring of the rod, were independently evaluated for association with PJK based on Lenke type. Multivariate logistic regression with backward elimination was performed to identify risk factors for PJK.

RESULTS

Overall PJK incidence was 7.05% and varies based on Lenke type (Lenke 1, 6.35%; Lenke 2 and 4, 4.39%; Lenke 3 and 6, 11.64%; and Lenke 5, 8.49%; p = .06). Among patients with Lenke 1 curves, risk factors for PJK were loss of kyphosis after surgery, and stopping caudal to the upper end vertebra (UEV). The risk of developing PJK increases by 7.1% with each lost degree of kyphosis compared with preoperation that occurs after the instrumentation is placed. For Lenke 2 and 4 curves, loss of kyphosis and more lordotic (negative) RCA were risk factors for PJK. For Lenke 3 and 6 curves, larger preoperative T5-T12 kyphosis was the only significant risk factor for PJK. Upper instrumented vertebra (UIV) at or cephalad to the UEV was associated with increased risk of PJK in Lenke 5 curves, which was contrary to the finding for Lenke 1 curves. No significant correlation was found between sagittal pelvic parameters and developing PJK.

CONCLUSION

The incidence of PJK in patients after surgery for AIS is 7.05% and varies based on Lenke type. Loss of kyphosis, larger preoperative kyphosis, UIV caudal to the proximal UEV (Lenke 1), UIV at or cephalad to the UEV (Lenke 5), and decreased RCA were the major risk factors for PJK in AIS.

LEVEL OF EVIDENCE

Level II.

Recurrence of Deep Surgical Site Infection in Cerebral Palsy After Spinal Fusion Is Rare

STUDY DESIGN

Retrospective review of prospective registry.

OBJECTIVES

To assess the following in children with cerebral palsy (CP) who develop deep surgical site infection (DSSI) after spinal fusion: (1) rate of infection recurrence after treatment; (2) treatments used; (3) radiographic outcomes; and (4) differences in Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) scores versus those of children with no infection (NI).

SUMMARY OF BACKGROUND DATA

Studies show high rates of surgical site infection in patients with CP but do not address late recurrence or quality-of-life effects.

METHODS

One hundred fifty-one children with CP underwent spinal fusion surgery from 2008 through 2011 and had ≥2-year follow-up. Patients who developed DSSI were compared with patients with NI. Student t tests were used to analyze deformity; analysis of variance was used to analyze CPCHILD scores in both groups preoperatively and at final follow-up.

RESULTS

Eleven patients developed DSSI. Causative organisms were polymicrobial infection (5 cases), Escherichia coli (2 cases), and Proteus mirabilis, Staphylococcus aureus, Enterococcus faecalis, and Peptostreptococcus (1 case each). All patients underwent irrigation and debridement and received at least 6 weeks of antibiotics. Six had negative-pressure-dressing-assisted wound closure; 5 had primary closure. At mean 4-year follow-up (range, 3-5 years) no patient had recurrent infection. From immediate postoperative to final follow-up, no patient had significant loss of coronal curve (p = .77) or pelvic obliquity (p = .71) correction. However, at final follow-up, comfort and emotions, overall quality-of-life, and total CPCHILD scores in the DSSI group were significantly lower compared with the NI group (p = .005, .022, and .026, respectively).

CONCLUSIONS

In children with CP who developed DSSI after spinal fusion, there was no recurrence of infection or deformity after infection treatment. CPCHILD scores in patients with DSSI were lower compared with the NI group.

MRI Screening in Operative Scheuermann Kyphosis: Is it Necessary?

STUDY DESIGN

Patients with preoperative spine magnetic resonance imaging (MRI) studies from a prospective multicenter study of operative adolescent Scheuermann kyphosis (SK).

OBJECTIVES

To investigate the usefulness of MRI screening in operative planning for SK surgeries.

SUMMARY OF BACKGROUND DATA

Neural axis abnormalities in operative SK have not been previously studied with MRI screening, despite its use.

METHODS

One orthopedic surgeon and two radiologists evaluated all images retrospectively. Radiographs were evaluated for kyphosis apex and magnitude. MRIs were evaluated for spinal cord abnormalities, epidural lipomatosis, location and number of vertebral wedging, Schmorl nodes and posterior disc herniations, frequency of spondylolysis, etc. The relationship of these pathologies to the kyphosis apex was explored. This group was compared to a surgical SK group without preoperative MRIs.

RESULTS

Eighty-six patients with MRIs, mean age 16.3 years, 64% male, and a mean preoperative kyphosis of 75.9° were evaluated. There were 17 spinal cord abnormalities. Low-lying conus was found in 2 patients, and syrinx in 15 (no Chiari malformations). Epidural lipomatosis was found in 49 patients, average of 5.7 levels. Anterior vertebral wedging occurred in all (mean 4.7 levels). Posterior disc herniations averaged 5.2 levels/patient and 1.8 levels caudad to the apex. Spondylolysis was reported in 8.1%. Four cases (4.7%) had the operative plan changed as a result of the preoperative MRI: two due to neural compression, one due to disc herniation and one due to a spinal cord draped over the apex. Thirty-one patients did not receive an MRI; there were no significant differences between the two groups. The rate of postoperative neurologic change was 3.5% in the MRI group and 3.2% in the no-MRI group.

CONCLUSIONS

Based on 4.7% of cases requiring a change in the operative plan as a result of preoperative MRI, the authors recommend considering performing screening MRI in operative SK patients.

Novel osmotin inhibits SREBP2 via the AdipoR1/AMPK/SIRT1 pathway to improve Alzheimer's disease neuropathological deficits

Extensive evidence has indicated that a high rate of cholesterol biogenesis and abnormal neuronal energy metabolism play key roles in Alzheimer's disease (AD) pathogenesis. Here, for we believe the first time, we used osmotin, a plant protein homolog of mammalian adiponectin, to determine its therapeutic efficacy in different AD models. Our results reveal that osmotin treatment modulated adiponectin receptor 1 (AdipoR1), significantly induced AMP-activated protein kinase (AMPK)/Sirtuin 1 (SIRT1) activation and reduced SREBP2 (sterol regulatory element-binding protein 2) expression in both in vitro and in vivo AD models and in Adipo^-/- mice. Via the AdipoR1/AMPK/SIRT1/SREBP2 signaling pathway, osmotin significantly diminished amyloidogenic Aβ production, abundance and aggregation, accompanied by improved pre- and post-synaptic dysfunction, cognitive impairment, memory deficits and, most importantly, reversed the suppression of long-term potentiation in AD mice. Interestingly, AdipoR1, AMPK and SIRT1 silencing not only abolished osmotin capability but also further enhanced AD pathology by increasing SREBP2, amyloid precursor protein (APP) and β-secretase (BACE1) expression and the levels of toxic Aβ production. However, the opposite was true for SREBP2 when silenced using small interfering RNA in APPswe/ind-transfected SH-SY5Y cells. Similarly, osmotin treatment also enhanced the non-amyloidogenic pathway by activating the α-secretase gene that is, ADAM10, in an AMPK/SIRT1-dependent manner. These results suggest that osmotin or osmotin-based therapeutic agents might be potential candidates for AD treatment.

Tobacco chewing and risk of gastric cancer: a case-control study in Yemen

This study aimed to assess the risk factors for gastric cancer in Yemen. A hospital-based case-control study of 70 cases and 140 controls was carried out in Sana'a city between May and October 2014. A structured questionnaire was used to collect information through direct interview. Living in rural areas, tobacco chewing and drinking untreated water were significant risk factors for gastric cancer. Frequent consumption of chicken, cheese, milk, starchy vegetables, cucumber, carrots, leeks, sweet pepper, fruit drinks, legumes and olive oil were associated significantly with decreased risk of gastric cancer. Multiple logistic regression analysis showed that chewing tobacco and frequent consumption of white bread were associated with increased risk of gastric cancer, whereas frequent consumption of chicken, cooked potatoes and fruit drinks had an inverse association. Risk of gastric cancer can be prevented by health education and increasing community awareness.

Subclassification of GMFCS Level-5 Cerebral Palsy as a Predictor of Complications and Health-Related Quality of Life After Spinal Arthrodesis

BACKGROUND

The Gross Motor Function Classification System (GMFCS) of cerebral palsy categorizes patients by mobility. Patients at GMFCS level 5 are considered the most disabled and at high risk of hip and spine problems, yet they represent a wide spectrum of function. Our aim was to subclassify patients at GMFCS level 5 who underwent spinal arthrodesis on the basis of central neuromotor impairments and to assess whether subclassification predicted postoperative complications and changes in health-related quality of life.

METHODS

Using a prospective cerebral palsy registry, we identified 199 patients at GMFCS level 5 who underwent spinal arthrodesis from 2008 to 2013. Patients were assigned to subgroups according to preoperative central neuromotor impairments: the presence of a gastrostomy tube, a tracheostomy, history of seizures, and nonverbal status. Nine percent of patients had 0 impairments (GMFCS level 5.0), 14% had 1 impairment (level 5.1), 26% had 2 impairments (level 5.2), and 51% had 3 or 4 impairments (level 5.3). The Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire was used for preoperative and postoperative health-related quality-of-life outcome assessments, and major complications were recorded.

RESULTS

The rate of major complications increased significantly with higher GMFCS level-5 subtype (p = 0.002), with 12% at level 5.0, 21% at level 5.1, 31% at level 5.2, and 49% at level 5.3. Five of the 7 patients who died within the follow-up period were at level 5.3. No significant differences were found among subgroups with respect to the magnitude of correction of the major coronal curve or pelvic obliquity. Preoperative and final follow-up CPCHILD total scores decreased significantly from GMFCS level 5.0 to level 5.3. However, no significant differences were found by subgroup with respect to the magnitude of improvement in CPCHILD total scores from the preoperative to the final follow-up evaluation (p = 0.597).

CONCLUSIONS

Stratification based on central neuromotor impairments can help to identify patients with cerebral palsy at GMFCS level 5 who are at higher risk for developing complications after spinal arthrodesis.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Are We Prescribing Our Patients Too Much Pain Medication? Best Predictors of Narcotic Usage After Spinal Surgery for Scoliosis

BACKGROUND

Physicians play a role in the current prescription drug-abuse epidemic. Surgeons often prescribe more postoperative narcotic pain medication than patients routinely need. Although narcotics are effective for severe, acute, postoperative pain, few evidence-based guidelines exist regarding the routinely required amount and duration of use post-hospital discharge.

METHODS

Patients in a prospective cohort undergoing posterior spinal fusion for idiopathic scoliosis were asked preoperatively to rate their pain level, the level of pain expected each week postoperatively, and their pain tolerance. Post-discharge pain scores and narcotic use were reported at weekly intervals for 4 weeks postoperatively. Demographic data, preoperative Scoliosis Research Society (SRS)-22 scores, operative details, perioperative data, and self-reported pain levels were analyzed with respect to their association with total medication use and refills received. Disposal plans were also assessed.

RESULTS

Seventy-two patients were enrolled, and 85% completed the surveys. The mean patient age was 14.9 years; 69% of the patients were female. The cohort was divided into 3 groups on the basis of total medication usage. The mean number of pills used in the middle (average-use) group was 49 pills. In postoperative week 4, narcotic usage was minimal (a mean of 2.9 pills by the highest-use group). Also by this time point, pain scores had, on average, returned to preoperative levels. Older age, male sex, a higher body mass index, and a higher preoperative pain score were associated with increased narcotic use. Sixty-seven percent of the patients planned to dispose of their unused medication, although only 59% of those patients planned on doing so in a manner recommended by the U.S. Food and Drug Administration.

CONCLUSIONS

Postoperative narcotic dosing may be improved by considering patient age, weight, sex, and preoperative pain score. The precise estimation of individual narcotic needs is complex. Patient and family education on the importance and proper method of narcotic disposal is an essential component of minimizing the availability of unused postoperative medication.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Avoidance of "Final" Surgical Fusion After Growing-Rod Treatment for Early-Onset Scoliosis

BACKGROUND

Definitive "final" surgical fusion is the common end point for growing-rod treatment of early-onset scoliosis. However, final surgical fusion may be unnecessary for patients who have reached skeletal maturity with good alignment. This study characterizes patients who completed growing-rod treatment but did not undergo final surgical fusion.

METHODS

Using a multicenter early-onset-scoliosis database, we identified 167 patients who received growing-rod treatment from 1995 through 2010, reached skeletal maturity, and had a minimum 2-year follow-up after their last surgery. Thirty patients did not undergo final surgical fusion (observation group) and were compared clinically and radiographically with 137 patients who did undergo final fusion (final surgical fusion group).

RESULTS

No significant differences were found between the groups with regard to the age at which treatment was initiated (p = 0.127), distribution of diagnoses (p = 0.84), or number of lengthening procedures (p = 0.692). In the observation group, 26 patients retained the growing rods and 4 patients had them removed at the last surgery because of infection. The mean primary curve correction at the end of treatment was 48% (from an initial mean magnitude of 79° to a mean final curve of 41°) in the observation group compared with 38% (from 74° to 46°) in the final surgical fusion group. There was no significant difference in final curve magnitude (41° in the observation group and 46° in the final surgical fusion group; p = 0.182). The mean increase in trunk height was 30.5% in the observation group and 35% in the final surgical fusion group. The final trunk height in the observation group was not significantly less than that in the final surgical fusion group (p = 0.142).

CONCLUSIONS

Because of progressive ankylosis, avoiding final surgical fusion at skeletal maturity is a viable option for patients treated with growing rods for all diagnostic subgroups of early-onset scoliosis who have satisfactory final alignment and trunk height, a minimal gain in length at the last distraction, and no clinical or radiographic evidence of implant-related problems.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Correction of Pelvic Obliquity After Spinopelvic Fixation in Children With Cerebral Palsy: A Comparison Study With Minimum Two-Year Follow-up

STUDY DESIGN

Single institution cohort data were collected prospectively and reviewed retrospectively.

OBJECTIVES

This study aims to compare outcomes among three different instrumentation types: unit rod, iliac screws, and sacral alar iliac (SAI) screws in terms of pelvic obliquity correction in children with cerebral palsy (CP).

SUMMARY OF BACKGROUND DATA

The optimal choice for spinopelvic fixation in CP scoliosis with pelvic obliquity is controversial.

METHODS

Patients with minimum 2 years' follow-up were divided into three groups according to instrumentation type and matched based on preoperative pelvic obliquity and coronal major curve magnitude. Radiographic measurements included horizontal pelvic obliquity angle (PO), spinopelvic angle (SPA), coronal and sagittal Cobb angles, and T1 pelvic angle. Procedures were performed in one pediatric institution between 2004 and 2012. All measurements were performed by a single independent reviewer who was not involved in the procedures.

RESULTS

Seventy-seven patients (42 unit rod, 14 iliac screw, and 21 SAI screw) were included. Gender and age distribution was similar across all groups (56% males, 44% females, mean age 13.5 years). Mean follow-up was 3.6 years. Comparing pre- and postoperative measurements, there was a significant decrease (p < .05) in PO, SPA, and coronal major cob angle in all groups. No significant loss of correction occurred during follow-up. Postoperatively, TPA improved in all groups. Nonsymptomatic loosening was noted in 59% of unit rods, 57% of iliac screws, and 52% of SAI screws. One prominent iliac screw needed removal. One nonsymptomatic rod fracture, one infected pseudarthrosis, and one rod malposition occurred in unit rod group.

CONCLUSIONS

This study suggests that for correction of pelvic obliquity in cerebral palsy scoliosis, iliac and SAI screws were similar to the unit rod in comparative effectiveness and implant safety profile.

LEVEL OF EVIDENCE

Therapeutic study, Level III.

Clinical Characteristics and prognostic analysis of Triple-negative Breast Cancer: Single institute experience

BACKGROUND

Triple-negative breast cancer (TNBC) is a poor prognostic subset of breast cancer that lacks the benefit of specific targeted therapy.

MATERIALS AND METHODS

A prospective study of the clinical profile of triple negative breast cancer cases at a tertiary referral centre. The duration of the study period was 26 months and the median follow up period was ten months. A total of 111 invasive breast cancer patients were evaluated from 1st August 2009 to 31st October 2011. We examined TNBC patients with respect to clinicopathological parameters, adjuvant chemotherapy regimens and relapse free survival.

RESULTS

In our study, patients were young (median age at presentation, 47yrs), premenopausal (54%), tumour size was discordant with lymph node positivity, the histology was predominantly intraductal carcinoma (90%), histological grade higher than two (90%). Relapses were early and preferential visceral (32%) and CNS metastasises (11.7%). 91% of patients were eligible for adjuvant therapy but only 80% of the patients could complete full course of adjuvant chemotherapy. Anthracycline-based regimens (43%), sequential anthracycline and taxane-based regimen (24%) and other regimes like CMF (13%) were used as adjuvant chemotherapy in eligible TNBC patients. Median relapse free survival in patients following adjuvant chemotherapy was around 10 months at last follow-up.

CONCLUSIONS

Patients with TNBC have aggressive clinicopathological characteristics with early and higher rate of disease relapse and therefore derive inadequate benefit from current adjuvant chemotherapy. So, new treatment strategies in adjuvant chemotherapy for TNBC are needed.

What would be the annual cost savings if fewer screws were used in adolescent idiopathic scoliosis treatment in the US?

OBJECT

There is substantial heterogeneity in the number of screws used per level fused in adolescent idiopathic scoliosis (AIS) surgery. Assuming equivalent clinical outcomes, the potential cost savings of using fewer pedicle screws were estimated using a medical decision model with sensitivity analysis.

METHODS

Descriptive analyses explored the annual costs for 5710 AIS inpatient stays using discharge data from the 2009 Kids’ Inpatient Database (Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality), which is a national all-payer inpatient database. Patients between 10 and 17 years of age were identified using the ICD-9-CM code for idiopathic scoliosis (737.30). All inpatient stays were assumed to represent 10-level fusions with pedicle screws for AIS. High screw density was defined at 1.8 screws per level fused, and the standard screw density was defined as 1.48 screws per level fused. The surgical return for screw malposition was set at $23,762. A sensitivity analysis was performed by varying the cost per screw ($600–$1000) and the rate of surgical revisions for screw malposition (0.117%–0.483% of screws; 0.8%–4.3% of patients). The reported outcomes include estimated prevented malpositioned screws (set at 5.1%), averted revision surgeries, and annual cost savings in 2009 US dollars, assuming similar clinical outcomes (rates of complications, revision) using a standard- versus high-density pattern.

RESULTS

The total annual costs for 5710 AIS hospital stays was $278 million ($48,900 per patient). Substituting a high for a standard screw density yields 3.2 fewer screws implanted per patient, with 932 malpositioned screws prevented and 21 to 88 revision surgeries for implant malposition averted, and a potential annual cost savings of $11 million to $20 million (4%–7% reduction in the total cost of AIS hospitalizations).

CONCLUSIONS

Reducing the number of screws used in scoliosis surgery could potentially decrease national AIS hospitalization costs by up to 7%, which may improve the safety and efficiency of care. However, such a screw construct must first be proven safe and effective.

An Independent Evaluation of the Validity of a DNA-Based Prognostic Test for Adolescent Idiopathic Scoliosis

BACKGROUND

ScoliScore is a DNA-based prognostic test, designed and used to help to predict the risk of curve progression in patients with adolescent idiopathic scoliosis. The role of this test in clinical practice remains unclear as the published results of the ScoliScore have not been validated independently. The purpose of this study was to determine if the ScoliScore effectively predicted the risk of curve progression in patients with mild and moderate adolescent idiopathic scoliosis in two urban academic medical centers.

METHODS

One hundred and twenty-six patients with adolescent idiopathic scoliosis who met inclusion criteria at two centers were administered the ScoliScore test. Two groups were created: a progression group (those who had a Cobb angle of >40° or those who had undergone surgical fusion) and a non-progression group (those who had skeletal maturity without curve progression to 40°). ScoliScore values and risk levels were compared between the two groups. The negative predictive value was calculated for low-risk scores and the positive predictive value was calculated for high-risk scores.

RESULTS

There was no significant difference (p = 0.706) in the mean ScoliScore (and standard deviation) between patients with curve progression (107 ± 55 points) and those without curve progression (102 ± 62 points). There was also no significant difference (p = 0.399) in curve progression between patients with high-risk scores (26.7%) and those with low-risk scores (12.9%). The positive predictive value of the test was 0.27 (95% confidence interval, 0.09 to 0.55), and the negative predictive value was 0.87 (95% confidence interval, 0.69 to 0.96). ScoliScores and rates of progression were not affected by brace-wear.

CONCLUSIONS

ScoliScores did not differ between patients with and without curve progression, and the negative and positive predictive values were lower in our study than in the previously published validation study by the developers of the test. This may be due to differences in our test population, genetic variability, or failure of patients in the non-progression group to follow up.

Reliability and known-group validity of the Arabic version of the 8-item Morisky Medication Adherence Scale among type 2 diabetes mellitus patients

No validation study has previously been made for the Arabic version of the 8-item Morisky Medication Adherence Scale (MMAS-8(©)) as a measure for medication adherence in diabetes. This study in 2013 tested the reliability and validity of the Arabic MMAS-8 for type 2 diabetes mellitus patients attending a referral centre in Tripoli, Libya. A convenience sample of 103 patients self-completed the questionnaire. Reliability was tested using Cronbach alpha, average inter-item correlation and Spearman-Brown coefficient. Known-group validity was tested by comparing MMAS-8 scores of patients grouped by glycaemic control. The Arabic version showed adequate internal consistency (α = 0.70) and moderate split-half reliability (r = 0.65). Known-group validity was supported as a significant association was found between medication adherence and glycaemic control, with a moderate effect size (ϕc = 0.34). The Arabic version displayed good psychometric properties and could support diabetes research and practice in Arab countries.

Deep Wound Infections After Pediatric Scoliosis Surgery

STUDY DESIGN

Retrospective clinical and radiographic review.

OBJECTIVE

The purpose of this study was to evaluate the characteristics of deep wound infection, as well as the potential factors that correlate to surgical site infection (SSI) in spine deformity surgery.

SUMMARY OF BACKGROUND DATA

Preventing SSIs in pediatric spinal deformity surgery is a crucial task. Recent data have shown that antibiotic-loaded allograft and properly timed preoperative antibiotic administration decrease SSIs. However, there remain controversies over the appropriate preoperative antibiotic selection.

METHODS

We reviewed 851 spinal deformity surgeries that took place at a single institution from 2006 to 2010. In particular, preoperative and postoperative characteristics of the deep wound infections were evaluated.

RESULTS

Twenty-four patients had SSIs. The mean age at surgery in the infected cohort was 14 years, mean length of surgery was 8 hours, and median estimated blood loss was 2,482 mL (%EBV: 66%). Approximately 67% of the infected patients had bowel/bladder incontinence, and 71% had prolonged intravenous access perioperatively. According to culture results, the most effective antibiotic to treat the infections was vancomycin. Preoperative antibiotics were administered within 30 minutes of incision (hospital protocol) in only 12.5% (p = .001) and within 1 hour of incision in 54% of the cases. The wound status within 3 days of surgery is as follows: 38% intact, 29% significant wound drainage, and 33% wound dehiscence. Methicillin-resistant Staphylococcus aureus (MRSA) and oxacillin-resistant Staphylococcus epidermidis were associated with intact wounds, whereas gram-negative pathogens were seen in dehisced or draining wounds (p < .001).

CONCLUSIONS

The authors showed that their cohort of patients with infection had a high rate of draining wounds, MRSA infections, administration of antibiotics more than 1 hour ahead of incision, and prolonged need for intravenous access after surgery. Efforts to mitigate these associations by using vancomycin prophylactically, doing meticulous wound closure to prevent drainage or dehiscence, and delivering antibiotics at an optimal time ahead of incision may lead to a decrease in infection rates in pediatric spinal surgery. Future prospective studies will be needed to validate this.